Hematemesis, Vomiting Gastroesophageal Reflux |
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Incidence | |
The gastroesophageal reflux is one of the most common causes of vomiting and hematemesis in the first year of life. It is not a massive hematemesis; the infants bring up traces of blood or of coffee-ground appearance. | |
Clinical significance | |
1. This leading symptom indicates that the suspected reflux has a clinical significance (esophagitis). | |
Etiology | Illustrations |
The cause of reflux is either a delayed maturation or, less frequently, a congenital malformation of the cardia, leading to an insufficient closure of the esophagogastric junction, and to a reflux of gastric contents and especially acid gastric juice in the esophagus and possibly into the larynx and the bronchi. | show details |
Pathology, anatomical types | Illustrations |
The described gastroesophageal reflux can be visualized with an upper gastrointestinal study with contrast or isotopes, and indirectly demonstrated by pH monitoring. | show details |
Pathophysiology | |
The pathophysiology depends on the type of complicated reflux. | |
Clinical presentation (history, findings, clinical skills) | Illustrations |
From the first day of life, regurgitation or vomiting occurs repeatedly following or during feeding with an acid smack, sometimes with force. Upright positions like sitting and standing and change of food to thickened feeds following development, and eating from the table lead to an amelioration of regurgitation and vomiting and may simulate recovery from reflux. In complicated reflux there are different signs and symptoms either as single or as combined leading symptoms: | show details |
Natural history | Illustration |
Without treatment, vomiting subsides in 60 % due to a maturation of the lower esophageal sphincter. Some of the patients remain only slightly symptomatic up to the 5th decade when the symptoms appear again. | show details |
Differential diagnosis | Illustrations |
The differential diagnosis includes all causes of vomiting, regurgitation and dysphagia. | show details |
Work-up examinations | Illustrations |
24-hour monitoring of the pH: A pH of less than 4 in more than 5 % (10 % in infants) of the registration time is abnormal (sensivity 100, and specifity 94 %). | show details |
Therapy | Illustrations |
Simple reflux: Medical treatment over a limited time with frequent, small and thickened feedings, semi-seated position, and, in case of severe reflux, with Histamin H2 receptor antagonists. Indications for surgery: Hiatal hernia, severe types of complicated reflux, resistance to medical treatment or absent adherence, and in neurological diseases. In addition, in some patients following repair of an esophageal atresia, gastroschisis and omphalocele and diaphragmatic hernia. Open or laparoscopic Nissen's or anterior Thal-Ashcraft's fundoplication. | show details |
Prognosis | |
Longterm results of medical treatment up to adulthood are not available.
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